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Alternatives to Psychiatric Hospitalization

One of the fundamental questions I am often asked is how to help a loved one who is going through severe emotional distress without going to a hospital setting. As someone who has worked for a number of years in an inpatient setting I am very familiar with the issues people have with hospital stays. In this article I want to outline some of the tools people can use to assist someone through a crisis without having to go to a hospital. At the same time, I do believe that for some people in some circumstances a hospital stay is warranted. If someone who is opposed to psychiatric care finds themselves in a hospital setting during this time, I will explain some of the process of a hospital stay and how best to navigate this experience.

Psychiatric Hospitalization

There are a number of reasons people do not want to go to a hospital that make a lot of sense. Let’s start at the beginning. Someone who is struggling in a crisis is looking for additional supports to help them navigate a deeply challenging experience. Sadly there are no strong options for someone who is in the throes of a deep crisis and people are generally steered toward a hospital for an evaluation.

For friends and family members who are worried about an individual this can mean that they will call for a welfare and safety check to the authorities in a municipality. For some people in the depths of a crisis, a visit by a police officer can worsen the feelings of panic and anxiety. For people of color, a visit by a police officer can feel extremely dangerous and can lead to acting in ways that could escalate and worsen the situation. Some cities have shifted out of direct confrontation by sending mental health specialists who can assess the situation in a less dangerous way.

While many people are willing to go to a hospital setting voluntarily, some individuals will not- and this can lead to force being applied to bring a person in to an Emergency Department. Police officers forcibly taking someone who is crisis to a hospital while in restraints can further a feeling of traumatization and is a main reason people avoid the process of coming to a hospital.

The next reason that people avoid hospital settings for psychiatric care is the problem with many emergency departments throughout the country. They are not adequately set up for mental health care. Generally all emergency departments are chaotic, overwhelming and easily intimidating. Throughout the U.S. a lack of acute inpatient hospital beds is leading to increased stays in Emergency Departments with some people staying for up to 2-3 days waiting for a room (boarding) to become available. If someone is already in crisis, this can increase a sense of frustration, distress and agitation. Usually one is warehoused in a small room with few amenities besides regular meals, television and a nurse who can provide “as needed” tranquilizers such as ativan or an antipsychotic.

The ED is the entry portal for a hospital stay and it is also the place where an ED physician will make their initial “assessment” and make a decision whether to involuntarily hold a person for a period of time. Here in Oregon that hold runs for 5 business days, not including weekends and holidays. That means the State can keep a person locked up in a hospital setting for about a week without letting them go. After the third business day, they are required to make a decision to either let the person go, let the hold run until its over, or take a person to mental health court to determine if they should be involuntarily committed, usually for a period of up to 180 days.

So if a person chooses to go to an ER due to severe crisis, there is a possibility that a doctor will require that person to stay there involuntarily for up to a week and possibly much longer if they are committed. The decision to place a “hold” on someone has to do with the likelihood of danger to themselves or others. If a person says they are actively suicidal with a plan to go home and use a shotgun to finish the job, it is highly likely a hospital will place the person on a hold. If a person is brought in by the hospital in a high state of agitation, confusion and psychosis, it is again highly likely that the person would be placed on a hold. On the other hand, if a person voluntarily comes to a hospital and states that they have been feeling increasingly agitated since their medications were changed and have been thinking about suicide without any specific plan, there is a strong possibility the person will be discharged or admitted voluntarily and will be allowed to leave when they want.

So the ED is a pivotal portal into the mental health system. The ED doctor, in conjunction with a psychiatrist make a very powerful choice to keep someone in crisis locked up involuntarily, allow them to be admitted voluntarily, or encourage them to discharge with outpatient supports.

Admit to Inpatient Unit

Once a person has been admitted to the hospital due to severe emotional distress, they are then transferred to an acute psychiatric unit. Like all cities, the city where I live (Portland, OR) has a number of different types of psychiatric units. Some of them are available to people who are more depressed and less intrusive, and some are available to people with a history of violent behavior. People are transferred to a specific unit based on one’s history, if they are previously known to the ER, or due to their behavior in the ER. For example, a sad and quiet 65 year old woman with a long history of depression is likely to be transferred to a psychiatric unit that is fairly calm. On the other hand, someone who presents as floridly psychotic, loud and intense in manner, is likely to be transferred to psychiatric units that tend to be more chaotic and disorganized.

Increasingly, however, hospitals are reducing psychiatric beds, which leads to less options if someone is in crisis. That means there is more intermingling with people who are depressed and suicidal, with people who are experiencing severe psychosis and those that are intrusive and sometimes predatory. This makes the inpatient hospital experience even less inviting for some who are considering it an option.

Once arriving on a psychiatric unit, staff will admit the person, provide information about the unit and offer paperwork to sign. The main things that happen in the psychiatric unit include:

1- Meeting a Psychiatrist

This doctor will likely spend a short period doing an “intake” that includes asking questions in order to learn the medical, social and mental health history of a patient. From that intake, the doctor almost invariably prescribes medication based on a preliminary diagnosis. If a person has already been on medication, the doctor may keep the medication the same or may change the medication. If they have never been on medication, the doctor will almost always start the person on a psychiatric drug.

Traditionally the medications prescribed are based on the diagnosis. Anti-depressants such as zoloft and
prozac are prescribed for depression and anxiety. Mood stabilizers such as depakote and lithium are prescribed for episodes of mania and depression with or without psychotic features. And anti-psychotics such as zyprexa and risperdal are prescribed for patients with psychotic features. Sometimes benzodiazapenes are prescribed for those with symptoms of anxiety. Sleep medications such as trazadone are also commonly prescribed.

Though these medications have generally been prescribed along these diagnostic lines, they have become increasingly jumbled so that antipsychotics are increasingly prescribed for all mental health concerns including anxiety, depression and insomnia.

When on a hospital hold, a patient is not required to take medications so they can make the voluntary choice to take some, all or none of the drugs prescribed to them. If a person has been involuntarily committed for a period of 180 days, the doctor can now force a person to take psychiatric drugs, via injection if the person will not take them orally. The doctor can also prescribe whatever types of medications and dosage they think is reasonable without the patient having any say. There has been an immense push to make these court committed patients stay on these drugs long after they have been released from a hospital setting via mandated Assisted Outpatient Treatment. This means that many people who have been court committed and are released to a home environment must take long acting antipsychotic psychiatric drugs such as risperdal consta or Haldol decanoate shots that can last many weeks.

Right now 43 states have implemented these AOT (Assisted Outpatient Treatment) laws. The belief is that many people go off their medications out of a lack of understanding of their mental illness (anosognosia) or due to side effects, and this leads to deepening psychosis and potential violence. Though I understand how some family members want some way to make sure their loved one is “medicated”, I believe this can come at a cost for a number of reasons.

The main reason is that this class of drugs (antipsychotics) often cause tremendous side effects such as akathisia, restlessness, sedation, hypersomnia, cognitive impairment and loss of libido. On a long term level, this class of medications often cause obesity, diabetes, compounded metabolic disorders, tardive dyskinesia and often lead to early death. I believe it is simply unethical, and frankly unconstitutional, to mandate that a person take a health damaging drug in perpetuity without their consent.

The other reason I have serious concern with these Assisted Outpatient Treatment laws is that one single doctor is often responsible for the drug regime the person must take. They can arbitrarily decide to put people on multiple combinations of drugs at varying dosages, sometimes very high. The patient has no recourse, no way to appeal to a higher authority if he thinks he is overmedicated or given a poor combination of psychiatric drugs. I have seen doctors put court committed people on a huge assortment of drugs at high doses (polypharmacy) that leaves an individual with severe side effects and complications.

Finally, on a simply strategic level, many people are mandated to take psychiatric drugs throughout their court commitment process (180 days) but once they leave they have the choice to stop taking the psych drugs. Many people do, and if they do it quickly, or via cold turkey, this can lead to severe withdrawal symptoms and the possibility of recurring psychosis created by the quick taper off a drug (iatrogenically manufactured psychosis). So in essence we are comfortable with forcing people to take drugs until they are no longer committed, then watch as they stop taking the drug, destabilize into psychosis and then return to the hospital for a long term merry-go-round that does nothing to “heal” the individual, and largely harms their health and well being.

So to sum up, when a person first sees a psychiatrist in a hospital setting, they are likely to either start, or adjust the medications a person is already on. What medications they decide on, and in what dosages, is really up to the psychiatrist. Those decisions can have enormous impact on the health and wellbeing of the patient and there is generally little or no conversation about side effects, long term health complications or problems with withdrawing off these meds. Often, the patient is in such distress that the idea of finding some relief makes sense. In a best case scenario, the patient would have access to a broad array of data discussing the efficacy and problematic effects of the drug they are being prescribed. A patient would then have a period of time to evaluate the medications being offered before making a decision. Unfortunately true informed consent is not part of the hospitalization experience. One of the best “quick-check” ways of examining the effects of a drug is to go to a website where first hand accounts are given. Askapatient.com is a great site where you can plug in a drug you are interested in and often see up to a 1000 reviews by folks who have first hand experience taking that drug over prolonged periods of time.

2- Meeting the County Investigator

In Oregon, each county has a number of county investigators who’s job is to interview a patient if they have been placed on an involuntary psychiatric hold. Generally, an investigator will meet with the patient the day after they have arrived. They will talk to the patient, family and friends to determine if the hold should remain in place due to “a danger to self or others.” After three business days, if they decide the person remains a danger to self or others, they can recommend a hearing before a judge to determine if that person should be committed up to 180 days.

The County Investigator holds a lot of power and essentially acts as the gate keeper to drop a hold, allowing a patient to leave, or to require them to stay and face a court commitment hearing.

Because of a strong lack of State Hospital beds, there is increasing pressure to drop holds. The vast majority of folks who come into a hospital setting discharge within a few days. A large percentage of patients placed on holds have their holds dropped within a day or two. A smaller percentage see their holds “run” the full five business days. Some remain quasi-voluntarily on a 14 day diversion and a very small percentage go before a judge for a court commitment process.

In previous decades, inpatient hospitalization was often a lengthy process that could sometimes last months. This has really shifted towards the hospital being a turnstile environment where patients are admitted and discharged quite rapidly, generally while they are still unstable emotionally. Patients are discharged with an appointment set up with a medication provider to assess their med regime every month or two, and perhaps with a case manager or occasionally with a therapist if there is good insurance.

If you are a support person or family member and a loved one has been placed on a hold in a hospital, you are likely to receive a call from an investigator asking about the state of emotional health of your loved one. Family who stress concerns about emotional instability, psychosis, violent or suicidal thinking can sometimes steer a county investigator to ask for a court commitment. Other factors that can steer a county investigator towards endorsing an involuntary civil commitment process is if the patient acts out violently or suicidally in the hospital setting, or appears to be grossly psychotic and unable to care for his or herself. On the other hand, family members can also steer a county investigator away from a court hearing by refusing to testify at a hearing, or by downplaying behavior that is perceived as a danger to self or others.

3- The Social Worker/Discharge Planner

This person is responsible for making the appointments with the providers, case managers and therapists once a patient discharges. Though many people come to a hospital in part due to emotional distress from homelessness, they have little power to help a person find adequate housing and generally can only offer a couple days of shelter vouchers. Social workers also act as mediators between family members and doctors who often very challenging to reach. They can give information about length of stay, how the patient is doing on a unit (if a release of information is given) and medication regimes.

Most commonly, people are released after a few days with a discharge plan to return to a home environment with appointments with mental health providers. If a person is involuntarily committed due to ongoing fears of being a “danger to self or others”, that person is often sent to a State Hospital or a step down residential facility for a period of time to wait for stabilization.

So we have two twin main problems in hospitalization. One is that many people do not want to take a strong course of psychiatric drugs, and are especially fearful of being forcibly medicated if they are “acting out.” On the other hand, there are plenty of individuals and families of individuals who want to have more lengthy hospitalizations and respites to help people who are deeply fragile and are easily triggered into extreme states. But sadly, except for the more rare cases, most people are being shunted back into the world to try and receive outpatient care when they are struggling deeply. This usually consists of patchy appointments with providers for med checks and occasional meetings with case managers and occasionally therapists. This is almost always not enough for people who are in crisis. So in both cases- for people who don’t want to be hospitalized, and for those who do want a longer stay in hospital but don’t get them because insurance companies will only pay for a short stay- there is a need to explore alternatives to hospitalizations for those going through a mental health crisis.

Why Does Psychosis Occur?

First off we need to explore what the term psychosis means. This can include profound mania, hearing voices, becoming confused by bizarre thoughts, delusional thinking, odd somatic experiences such as feeling disconnected from the body, sensations of feeling “telepathic”, psychic, becoming extremely talkative, not sleeping for many days, paranoid, or many other types of extreme experience.

There are numerous theories as to why these experiences are taking
place. In the medical model, there is an emphasis on the likelihood of an inherent disease due to genetic factors. If this psychosis persists and one can rule out medical factors or adverse reactions to recreational drugs, an individual who experiences these states is often labeled with Bipolar, Schizophrenia or Schizoaffective Disorder. In the medical model, these illnesses are thought to be pervasive for life, though there is the possibility of remission. The medical model includes the idea that life stressors can trigger the disease process.

Those who have problems with the medical theory of “madness” tend to think that psychiatric labels tend to be very poor descriptions of a person and not based in scientific evidence. The idea of labeling someone who experiences a psychotic state with a diagnosis such as schizophrenia or bipolar has gained in popularity over the past 60 years since psychiatrists created a book to differentiate different psychiatric disorders known as the DSM (Diagnostic and Statistic Manual.) The DSM defines disorders as emotional distress that have on some level incapacitating to normal human functioning. They define each disorder with a constellation of symptoms that psychiatrists have agreed meet a threshold of illness.

For example, here is a link to the DSM definition of Schizophrenia. One of the main critiques of the medical model of mental illness is that definitions of mental illness are not based in any objective scientific test. They are simply sets of symptoms that a group of psychiatrists have decided constitute an illness. Unlike diabetes or cancer which has biological markers, schizophrenia does not have any biological markers that can be easily measured for a diagnosis. Doctors simply note symptoms and decide on a diagnosis. These diagnoses are often very fluid and someone can be diagnoses as bipolar by one doctor and as having schizophrenia by another.

Alternative Explanations for Psychosis

There are other models for explaining “first-break” psychosis. One main alternative model is that stress plus underlying childhood and early adulthood emotional trauma is the main contributor to the present psychotic state. In essence, toxic family of origin issues, poverty, emotional, physical and sexual abuse are main underlying factors for psychosis. There is an increasing body of evidence that links trauma and psychosis.

There is also a fair bit of evidence that nutrition and lifestyle patterns contribute to the potential for extreme states. If someone is susceptible to altered states, a diet high in processed and refined foods, sugar, caffeine, alcohol and drugs can contribute to destabilizing an individual and can lead to a psychotic break. There have been some remarkable studies here and here that show that diets high in vegetables and meat and low in carbohydrates and sugars (a more Paleo or ancestral diet) can be remarkably helpful for those susceptible to extreme states.

Finally, it is important to note that historically and cross culturally, experiences of extreme states are not seen as always due to “illness.” Possession states, spiritual rites, ecstatic ceremonies involving fasting, praying, lack of sleep and psychoactive plants have long been connected to extreme states and often seen as healthy experiences of spiritual transformation and celebration. Western notions of mental illness conform to what we as a society deem as normal and aberrant.

There are movements of people who experience extreme states who are trying to rename their experience outside of the medical model. Perhaps the most important of these groups are the folks at the Icarus Project. This is a group focused on peers with lived experience of extreme states helping other peers and honoring a wide variety of cultural and personal explanations of “madness” that don’t necessarily interlink with a medical model explanation of mental health.

To also add, there are many people who extreme some form of extreme state without it becoming a long life condition. These experiences of psychosis can be truly overwhelming and persist for long periods of time. Sometimes these experiences happen dud to drug reactions, a period of not sleeping or simply due to some unknown factors. There are many people who call these experiences “spiritual awakenings”, rebirths or kundalini rising experiences and see extreme states through the lens of spirituality. Folks who see their experience through this lens view these divergent experiences as a spiritual unfolding and outside of a medical sickness/wellness model.
My belief is that extreme states are engendered by a number of different factors including- personal susceptibility to extreme states, stress, trauma history, oppression, spiritual leanings, alcohol and drug usage and if radical medication changes have recently occurred. People from different cultures and backgrounds can have different language models for their experience and simple diagnostic language of Bipolar, schizophrenia or schizoaffective disorder do not adequately cover the full range of experience one is having.

Many people can recover from these time limited experiences of psychosis.extreme states. I know in my personal experience, I went through a number of years of intermittent extreme states and I could have easily been labeled as Bipolar or schizoaffective at the time (20 years ago). Those experiences faded and I was never medically diagnosed or treated and have gone on to live a good rich life outside of the medical model. For many people, there it can be easier to have multiple languages and ways of appreciating their extreme state experiences- sometimes using spiritual transcendent language and at others using a medical model lens.

Hospitalization

Those who experience psychosis and come to a hospital setting are almost always prescribed antipsychotics. These include the newer “atypical antipsychotics” such as risperdal, zyprexa, abilify, and geodon. They may also be prescribed older “typical” antipsychotics such as haldol. Antipsychotics tend to be sedating and tranquilizing. The atypicals were developed and marketed in the 90’s and thought to be far superior to the older typicals because of a smaller side effect profile and less potential for long term health problems. The older antipsychotics were specifically seen as dangerous due to the potential for “Tardive dyskinesia“, a form of irreversible muscle twitching that can be quite severe. In the 90’s I worked with a man labeled with schizophrenia who had been prescribed thorazine (an old school typical antipsychotic) for a decade and he had developed incontrollable rocking, shaking and spastic arm movements. This was very sad because he was a painter and he had tremendous difficulty using his brush for his artwork.

Though the newer atypicals have been heralded as a godsend for those experiencing ongoing psychosis, they tend to come with a wide variety of problems as well. On a short term bass they can cause such symptoms as dry eyes and mouth, blurring of vision, strong sedation, hypersomnia, libido loss, as well as extrapyramidal side effects such as akathisia and parkinsonian like tremors and shaking. It is common for people that experience these EPS symptoms to be prescribed an anticholinergic anti-parkinsonian drug such as cogentin as well as the atypical.

On a long term basis, they all tend to cause disorders such as obesity, diabetes, high cholesterol and heart disease, though there are some variations in their long term side effect profile. Those with a serious mental illness label such as Bipolar I and Schizophrenia die up to 25 years earlier than normal. Though socio-economic factors certainly play a role, there is a likelihood the long term health effects of the drugs are contributing to this early mortality rate.

Antipsychotics can be incredibly challenging to withdraw from as well. This class of drugs tend to work by blocking dopamine absorption. Dopamine is a neurotransmitter responsible for sending signals between neurons. On a crude level, it has been postulated that too much dopamine might cause some of the psychotic symptoms and therefore a drug that reduces available dopamine could reduce mania and psychosis. The longer a person takes one of these antipsychotics, the more habituated the body becomes to a drug that reduces available dopamine. If a person stops taking one of these drugs cold turkey, the body suddenly becomes flooded by dopamine and is likely to experience florid psychosis. Though some medical professionals will point to the underlying disease as the cause for the reoccurrence of psychosis, it is highly likely that the withdrawal effect off these drugs is playing a large role.

The longer one stays on these drugs, the larger the dose and the larger the prescription (polypharmacy) the harder it is to wean off of them. For many people, it becomes literally impossible as each attempt leads to a psychotic process. There is mounting evidence that taken over long periods of time, these antipsychotics can actually increase the susceptibility to psychosis, as well as cause tremendous health problems. This is a very clear article about the ongoing mounting evidence presented by Robert Whitaker.

In this article, Whitaker points to longitudinal studies done by scientists who examined how people fared when taking lonog term courses of antipsychotics verseus those who did not. Essentially, for those who took antipsychotics long term, there is a far greater chance of disability, hospitalizations and psychosis long term. This is an article about these longitudinal studies by Harrow and Wunderink. The evidence is clear that people who have discontinued antipsychotics or have never started them have a far better chance of recovery from initial psychosis.

Because of this, there are a number of people in the field who are now presenting an alternative model for managing crisis known as a “selective use model”. In this model, the best plan for initial psychosis is to avoid using the drugs altogether and see if the psychosis naturally dissipates. After that the next best plan is to try a low dose and then to try and taper the person off as quickly as possible. The selective use model is much more “evidence based” when taking into account the long term outcomes of the effect of antipsychotics.

Unfortunately, this is not what mainstream psychiatry believes is the best course and evidence based medicine. In hospitals and outpatient clinics, most still posit that early break psychosis is a sign of a chemical imbalance and a long term illness such as schizophrenia or bipolar disorder that will require a lifetime use of antipsychotics.

On a basic level, it is important to note that the theory that psychiatric drugs correct a chemical imbalance is simply false. To understand why this myth continues, please take a look at this great article by Chris Kresser. Essentially, this idea was presented as a way to establish the medical efficacy of these drugs for mental illness. However, no true scientific research has ever determined the exact nature of a chemical imbalance for mental illnesses, nor have they scientifically proved the idea that psychiatric drugs correct any imbalance.

Because of this it is essential that those who are experiencing a “first-break”, as well as their family members, take a long look at the pros and cons of starting one of these drugs. As tranquilizers, they can often be effective at reducing psychotic symptoms such as mania and hallucinations. For those who are experiencing extremely disturbing voices, sometimes commanding suicide or violence, any relief may seem worth the potential health risks. I believe we need to start seeing these antipsychotic medications for what they are, very potent tranquilizing drugs. They indeed work to quell “extreme state” symptoms such as florid psychotic mania, but long term they come at a cost to health.

Because of this long term information about the effect of antipsychotics, making the decision to start these drugs should be very carefully examined. In a hospital setting, someone in the throes of severe psychosis may not understand the ramifications of starting one of these drugs. Often a doctor prescribes this class of medication with little conversation due to the altered state of the patient. There is often little in the way of informed consent because it is somewhat impossible in that state.

Holistic Planning for those experiencing a psychotic episode

Complexity arises if a person has already started a course of antipsychotics and/or mood stabilizers and has been on them for an extended period of time and then goes into crisis. Probably the most common reason people with these diagnoses go into crisis is because they have gone off the psychiatric drugs. As I noted before, the body becomes habituated to the artificial changes in neurochemistry and the nervous system can easily go into shock when these drugs are removed, especially if they are stopped quickly or cold turkey. Those prone to extreme states and psychosis can then easily experience a recurrence of these psychotic symptoms that can lead to hospitalization. In this state, probably the smartest thing to do would be to reinstate the psychiatric drugs. Sadly, even though the drugs themselves may be causing quite a few side effects and health problems, a quick and sudden taper can create havoc on an already sensitive nervous system.

In general, if someone has been given a serious mental illness label and is on a number of psychiatric drugs, health complications will likely mount as the years roll by. It also becomes increasingly difficult to wean off the drugs, especially if the dosages are high and they are on multiple drugs (polypharmacy). Quick tapers and cold turkey easily leads to new symptoms of psychosis. Hospitalization can be a way of quickly reinstating the medications. However, family members and the labeled individual should take great care of how a psychiatrist intervenes at this point. Some doctors will decide that previous prescriptions were unwarranted and will quickly change meds, add meds or change and often augment dosages. Generally, these sudden changes can cause further stress on the nervous system and one should be very careful with making lots of changes without doing a great deal of research on the medication changes.

If a person has been labeled and is on a long term course of antispychotics and mood stabilizers, and health problems mount, the best time to wean off the drugs is in a setting with lots of emotional support and good nutrition. It is deeply important that the person tapers slooooowly as to avoid a relapse in psychotic symptoms. Most doctors do not advocate a slow taper but anecdotal evidence points to slow tapering being a much more effective and safe way of getting off meds if a person has decided to do that. The best guide to coming off meds can be found here. Some other resources include Beyondmeds.com, survivingantidepressants.com and benzobuddies.com.

For those who are looking for alternative approaches and if there is no imminent danger present, it is important to look at various holistic options for working with severe distress. These are some general guidelines for helping someone in this state.

1- Housing and support. Make sure the person has adequate housing and lives in a safe well maintained home that is relatively clean. This is a fundamental class issue and there are millions of people in the U.S. who are homeless or who live in substandard housing. This is a systemic issue that needs to be addressed. It is generally key to have a circle of support that provides very close care of the person from a week to several months. Round the clock care such as living with family members and close allies is often optimal but having the best and most loving support team is key here. It is important to watch out for burn out here and make sure there are multiple people involved in helping the individual to recover.

2- Nutrition. Healthy food is an extremely important part of working

through these extreme states. When someone is in a heightened or manic state, the body is asking for calming, rooting and grounding food. It is key to reduce foods that exacerbate distress such as caffeine, sugar and processed foods. Foods that are helpful include lots of vegetables and especially leafy greens, tubers such as sweet potatoes, beets and carrots.

Avoid “fast carbs” such as white wheat flour foods and choose whole grains such as quinoa, brown riceand amaranth for grains. Wild caught fish and game high in Omega 3 anti inflammatory oils are very good to add. Wild greens are also extremely dense and nutritious. My basic rule of thumb is to avoid “PAWCS”… Or Processed food, Alcohol and drugs, Wheat, Caffeine and Sugar. Some people feel sensitivities to other foods such as dairy, nightshades, corn or excessive fruit. It’s important to eliminate all allergenic inflammatory food if possible.

3. Destim. Creating an environment that is conducive towards feeling calm and relaxed is very important. That means lowering lights, reducing electronics, not having loud intense music or media playing, etc. Spending time in quiet natural spaces near flowers and trees can be immensely healing.

4. Structure. Having an organized plan throughout the day can be really helpful even if it just means eating at regular meal times. That can mean doing certain activities such as crafts, art projects, gardening, taking walks, knitting, playing games throughout the day. Talk based communication can often be really hard during an extreme state and non-verbal forms of connecting can be really helpful.

5. Finding Meaning. The experience of an extreme state can be very confusing and lonely. Most people do not understand when someone is going through strange and wild perceptions and thought patterns. It is key to find peers and helpers who is open to what the person is going through and willing to explore those places to help find meaning and understanding. When I went through my psychotic process as a much younger man I was deeply helped by an herbalist healer and a therapist. As a therapist I often help people who are going through these states and I can understand how isolating they can be. Often people turn away or avoid someone in these states and its key to have allies who are willing to stay present and open to the person’s experience.

6. Safety. For some people in this state there may be a desire to hurt oneself or

to act in ways that are endangering. This can be very tricky to manage and every situation is different. Round the clock care can be helping along with soothing talk and listening to what is going on for a person. Often these tendencies can be reduced with a lot of kindness, care, attention, good food, herbal approaches. But at times things can get out of hand and truly dangerous and at that point I think hospitalization is warranted. if at all possible it is best if family and friends brings the person to the hospital because the alternative is to call the police which is deeply traumatic and often dangerous if there is extreme volatility going on. Deciding how to manage this can be one of the hardest decisions for a loved one to make. But the paramount concern at that point is making sure everyone stays safe and unharmed.

7. Love. A key component to the healing process is having family and friends around that will provide warmth and care. Again, it is key to avoid too much “therapy” and instead focus the energy towards quieter activities such as playing light soothing music, crafts, coloring, time in a garden or nature walks. Love in this case generally means being with the person without judgement and avoiding heavy criticism, fear, shame and anger if at all possible. It does not mean unconditional acceptance of all actions and behavior. Certainly some behavior is off limits such as abusive language or actions or movement towards hurting self or others.

8. Herbs, supplements and drugs etc.

In general people who are looking for alternative ways of working through an extreme state are not taking psychiatric medications and are looking for other options. Every extreme state is different and every individual is different and so there is no hard and fast rules about how to help people in these situations but I will review a few basic ideas.

Generally gentle herbal approaches can be applied to anyone..but that comes with caveats. Some people are deeply sensitive and very few herbs are helpful. The basic idea is to think of using nourishing tonics and broths as nutrient dense vitamin and mineral rich supplements that can help repair and bring someone back to a steady grounded state. Infusions of oat straw, nettles. red clover and alfalfa are very helpful here. Take a look at this guide to doing this here…

Then making regular bone broth with herbs such as shitaki, maitake seaweeds and astragalus can be really nourishing as well. Here is an article on doing that here…

Traditional indigenous techniques of smudging with herbs such as sweetgrass, cedar and sage is very helpful as well as using aromatherapy sprays and diffusers with essential oils such as lavender, rosewood and sandalwood. You can purchase these items here.

“Visual herbal therapy” such as spending time in gardens, parks and nature is often key to helping someone in an extreme state. Massage with infused oils such as rose, lavender and lemon balm can really help a person to get grounded and return to center. You can purchase some of these items here.

My website herbs for mental health has a lot more information about these subjects. Take a look here.

Conclusion

Supporting a person who is experiencing psychosis in a holistic manner that is non primarily based on psychiatric drugs and the medical model can be challenging. But no more than ever, we need to create better models for helping people in crisis. There are enough people who are adverse to medications, are philosophically opposed to them or are worried about their long term effects on health, that its key to explore ways to help people outside of the medical model. Creating models and paradigms that allow for people to be gently supported through a psychotic episode without medication (or with a selective and “low-dose” model) is key to supporting healthy recovery. The good news is that with time, patience, good nutritional and emotional support and lots of love, healing is not only possible, it is probable.

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Hi Frank,Thanks for your thoughts. You make an interesting point about trying to fix one form of impairment (i.e. mental distress) with another (drug use). Indeed, the impairment created by antipsychotics is well documented, especially in the long-term studies. Many of the non-drug approaches for psychosis (including CBT for psychosis, Open Dialogue, and Hearing Voices Network) don”t try to medicalize psychosis, but seek to meet the experience, understand it, and find ways to work through the issues it may present.

The worst thing that ever happened to me, which I refer to as Psychiatric Abuse, was being called suicidal when I was not. I was treated like a dangerous animal, restrained, and put on 1:1 monitoring. I complained that the 1:1 people were physically and verbally abusive to me and were denying me basic privacy rights. I was told I was psychotic. I was not. This was even worse Psychiatric Abuse. This is the worst and pretty much only abuse I ever went through and had very little to do with “drugs. They gaslighted me, held me hostage, would not let me communicate with the outside, continuously called me psychotic, told me they were sending me to an institution for life, tried to force me onto Zyprexa, and finally, let me go. After I left, I found out my church had kicked me out, most of my friends that I had left claimed I was psychotic and that it never happened. One of my good friends sided with the hospital and claimed they were doing their job. I cried every day for months alone, hugged my dog and cried and cried and thought my life was over. At the time I was 55 years old. That incident may have nearly killed me, but it made me an activist.